Long-term outcome of male urethral hemangioma: a two-center study
Highlight box
Key findings
• This study revealed that transurethral hemostasis/electrocautery offers high long-term stability and minor complications for male urethral hemangioma, representing a safe and effective treatment option.
What is known and what is new?
• Systematic research on urethral hemangioma remains limited globally, and high-quality clinical data regarding its long-term prognosis are scarce.
• We investigated the long-term outcomes of male patients with urethral hemangioma after endoscopic surgery, with a focus on recurrence and complication rates.
What is the implication, and what should change now?
• Clinical practice should enhance awareness of this condition, improve early diagnosis rates, and individualize surgical approach selection to optimize the outcomes and quality of life of patients.
Introduction
Male urethral hemangioma is an exceedingly rare benign vascular tumor, constituting only approximately 2% of all genitourinary hemangiomas (1,2). While hemangiomas are frequently detected in regions such as the head, neck, and liver, they rarely exist in the urethra. The clinical significance of urethral hemangioma lies in its ability to cause characteristic “sexual activity-related hematuria”, which manifests as hematospermia, urethral bleeding, or gross hematuria following ejaculation, erection, or sexual intercourse. In severe cases, it may lead to blood clot formation, resulting in bladder tamponade or urinary retention (3,4). Due to its nonspecific clinical presentations and the lack of awareness among urologists, it is often misdiagnosed as seminal vesiculitis, urinary tract infection, or prostatitis, resulting in delayed treatment (3,5).
The first documented case of urethral hemangioma was reported by Klotz in 1895 (6), while the mechanism of bleeding after sexual activity was initially proposed by Hayashi et al. in 1997 (7). With the widespread adoption of endoscopic techniques, the diagnosis rate of this condition has improved in recent years. Huang et al. (4) reported 39 cases in 2020, indicating a peak incidence age of 30–59 years. In their study, disease course ranged from several months to decades, suggesting a chronic and protracted nature. Nevertheless, systematic research on urethral hemangioma remains limited globally, and high-quality clinical data regarding its long-term prognosis are scarce.
Within the broader spectrum of genitourinary vascular lesions, reports of similar rare cases can further underscore the diagnostic and therapeutic challenges posed by these conditions. For example, Liu et al. reported an extremely rare case of primary spermatic cord lymphangioma in a child, noting that although these lesions are benign, their specific locations and insidious clinical presentations increase the likelihood of misdiagnosis or oversight (8). Similarly, although urethral hemangioma is benign, its bleeding tendency can significantly affect the quality of life and psychological well-being of patients. Particularly, recurrent hematuria and hematospermia frequently lead to anxiety symptoms and sexual dysfunction (9). Currently, the diagnosis of urethral hemangioma primarily relies on urethrocystoscopy, with typical manifestations being a pink or dark red venous mass-like elevation at the 6 o’clock position of the distal verumontanum and external urethral sphincter (4,10). In terms of treatment, patients with occasional or minor bleeding may be managed conservatively with medications, such as 5α-reductase inhibitors, whereas endoscopic procedures, including plasma resection, electrofulguration, and laser ablation, are recommended for those with recurrent or refractory bleeding (4,11,12). Although short-term efficacy is generally favorable, there are limited systematic follow-up data on long-term postoperative recurrence rates and complications, such as urethral stricture and urinary incontinence.
Therefore, this study aimed to investigate the long-term outcomes of male patients with urethral hemangioma after transurethral hemostasis/electrocautery through a dual-center retrospective clinical analysis. Specifically, this study focused on recurrence rates and the incidence of complications to provide more prospective evidence-based insights for clinical management. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0116/rc).
Methods
Clinical data
All patients with urethral hemangioma were enrolled from Affiliated Hospital of Hebei University and The Second Affiliated Hospital of the Army Medical University. The patients were diagnosed with urethral hemangioma based on transurethral cystoscopy and had complete clinical data. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Medical Ethical Committees of The Second Affiliated Hospital of the Army Medical University. All patients provided written informed consent.
Inclusion and exclusion criteria
The inclusion criteria were as follows:
- Surgery start date was July 2018, and the surgery completion date was December 2023;
- Patients were diagnosed with urethral hemangioma based on transurethral cystoscopy;
- Male gender;
- Patients experiencing their first episode;
- Patients aged older than 18 years.
The exclusion criteria were as follows:
- Patients were diagnosed only based on clinical suspicion; the urethral hemangioma diagnosis could not be confirmed, as transurethral cystoscopy was not conducted;
- Patients who were clinically suspicious of having malignant tumors;
- Patients aged less than 18 years;
- Female gender;
- Patients without complete clinical data.
Treatment strategies
All patients were treated for urethral hemangioma and underwent transurethral hemostasis/electrocautery. The procedure was initiated at the external urethral opening under general or spinal anesthesia, with continuous irrigation to keep the surgical area clear. The area surrounding the seminal vesicles and the membranous urethra was given special attention. In the absence of a clear protrusion, an electrocautery loop was used to apply pressure for a second time. Suspicious regions were addressed using hemostasis or electrocautery at low temperatures. Clear visibility was ensured during resection, and the depth of resection was limited to the mucosal layer to avoid muscular layer manipulation. The laser parameters included 10 HZ, 20 HZ, 30 HZ, 0.6 J, 1 J, 40 W, 100 W, 20 W, and 30 W.
Outcomes and follow-up
Outcome measures included perioperative safety, long-term recurrence, and complications. Perioperative outcomes included procedural time, preoperative hemoglobin level, postoperative hemoglobin level, intraoperative complications, indwelling urinary catheter time, transfer to intensive care unit (ICU), and postoperative complications. Long-term complications comprised urinary incontinence, retrograde ejaculation, urethral hemorrhage, ejaculation pain, urethral stricture, and hematuria. Recurrence was defined as cystoscopically confirmed, radiographically detected, and clinically diagnosed urethral hemangioma following the initial surgery. Cystoscopy is often recommended for patients suffering from urethral complications. When a patient presented with macroscopic hematuria, especially with sexual activity, it was regarded as a recurrence. The cut-off date for inclusion in our study was December 2023. Therefore, the follow-up length for this group was sufficient. Follow-up data, collected through telephone and outpatient reviews, documented the recurrence of hemangioma and any long-term complications. The follow-up period was calculated from the surgery date to the event date and is expressed in months.
Statistical analysis
Raw data were analyzed through a descriptive method. Normally distributed continuous data are presented as mean and standard deviation (SD), and non-normal continuous data are expressed as median and interquartile range (IQR). Categorical variables are expressed as the number of cases (n) and percentages (%). All statistical analyses were conducted using SPSS 25.0 software.
Results
Demographic characteristics
In total, twenty-nine patients with urethral hemangioma met our inclusion and exclusion criteria. Mean age and body mass index (BMI) were 41.9±11.2 years and 25.0±2.4 kg/m2, respectively. The duration from disease presentation to diagnosis was extended, and the median time was 6 months. Most patients experienced symptoms associated with their sexual life (after ejaculation: n=12, 41.3%; sexual life: n=13, 44.8%). The symptoms of only 4 patients (13.7%) were associated with their erectile function, and we could not determine their association with sexual life or other reasons. None of the patients had abnormally developed vessels, cutaneous hemangiomas, Klippel-Trenaunay syndrome, or Sturge-Weber syndrome. The symptoms were not treated with antiplatelet medicine or hormone therapy. Of twenty-nine patients, 5 (17.2%) had a history of chronic urinary tract infection. None of the included patients had a history of transurethral procedures, coagulation disorder, or a family history of hemangioma. Table 1 presents the demographic characteristics of patients with urethral hemangioma.
Table 1
| Characteristic | Values |
|---|---|
| Age, years | 41.9±11.2 |
| BMI, kg/m2 | 25.0±2.4 |
| Course of disease, months | 6.0 [2.0–24.0] |
| Incentive | |
| After ejaculation | 12 (41.3) |
| Sexual life | 13 (44.8) |
| After erectile | 4 (13.7) |
| Combined disease | |
| Abnormally developed vessels | 0 (0.0) |
| Cutaneous hemangioma | 0 (0.0) |
| Klippel-Trenaunay syndrome/Sturge-Weber syndrome | 0 (0.0) |
| Hormone therapy prior to urethral hemangioma onset | 0 (0.0) |
| Anticoagulation used prior to urethral hemangioma onset | 0 (0.0) |
| History of alcohol consumption | 12 (41.3) |
| History of smoking | 16 (55.1) |
| Family history of hemangioma | 0 (0.0) |
| Past medical history | |
| History of transurethral procedures | 0 (0.0) |
| History of coagulation disorder | 0 (0.0) |
| History of urinary tract chronic infection | 5 (17.2) |
Data are presented as mean ± standard deviation, median [IQR] or n (%). BMI, body mass index; IQR, interquartile range.
Perioperative characteristics
Table 2 summarizes the perioperative characteristics of male patients with urethral hemangioma. Twenty-nine patients underwent surgery, among whom 16 (55.2%) underwent transurethral hemostasis, and 13 (44.8%) underwent transurethral electrocautery. All procedures were conducted successfully without transfer to the ICU. The median size of tumors was 4.0 [3.0–5.0] mm, and 89.6% of patients had multiple tumors. The median procedural time was 20.0 [10.0–37.5] minutes. The preoperative and postoperative median hemoglobin levels were 134.1±12.0 and 131.3±9.4 g/L. No intraoperative complications, such as hemorrhage and urethral injury, were recorded. The indwelling catheter was kept in place for a median duration of 5.0 days (IQR, 2.0–6.0 days). None of the patients required unplanned re-catheterization or experienced postoperative complications, including urethral stricture, urinary incontinence, retrograde ejaculation, urethral bleeding, gross hematuria, or ejaculatory pain.
Table 2
| Characteristic | Values |
|---|---|
| Procedure | |
| Transurethral hemostasis | 16 (55.2) |
| Transurethral electrocautery | 13 (44.8) |
| ASA grade | |
| I | 11 (37.9) |
| II | 18 (62.1) |
| Procedure time, minutes | 20.0 [10.0–37.5] |
| Tumor size, mm | 4.0 [3.0–5.0] |
| Preoperative hemoglobin, g/L | 134.1±12.0 |
| Postoperative hemoglobin, g/L | 131.3±9.4 |
| Number | |
| Solitary | 3 (10.3) |
| Multiple | 26 (89.7) |
| Intraoperative complications | 0 (0.0) |
| Indwelling urinary catheter time, days | 5.0 [2.0–6.0] |
| Transferred to ICU | 0 (0.0) |
| Postoperative complications | |
| Indwelling urinary catheter again | 0 (0.0) |
| Urethral stricture | 0 (0.0) |
| Retrograde ejaculation | 0 (0.0) |
| Urinary incontinence | 0 (0.0) |
| Urethral hemorrhage | 0 (0.0) |
| Gross hematuria | 0 (0.0) |
| Ejaculation pain | 0 (0.0) |
Data are presented as mean ± standard deviation, median [IQR] or n (%). ASA, American Society of Anesthesiologists; ICU, intensive care unit; IQR, interquartile range.
Long-term follow-up outcomes
Long-term follow-up outcomes are presented in Table 3. No cases of disease recurrence were observed during a median follow-up length of 50.0 months (IQR, 35.0–75.5 months). Furthermore, no long-term complications were recorded during the surveillance period, including urinary incontinence, retrograde ejaculation, urethral bleeding, ejaculatory pain, urethral stricture, and hematuria. All patients remained symptom-free at their last follow-up assessment.
Table 3
| Follow-up | Values |
|---|---|
| Follow-up time, months | 50.0 [35.0–75.5] |
| Recurrence | 0 (0.0) |
| Complications | |
| Urinary incontinence | 0 (0.0) |
| Retrograde ejaculation | 0 (0.0) |
| Urethral hemorrhage | 0 (0.0) |
| Ejaculation pain | 0 (0.0) |
| Urethral stricture | 0 (0.0) |
| Hematuria | 0 (0.0) |
Data are presented as median [IQR] or n (%). IQR, interquartile range.
Discussion
In this study, twenty-nine male patients with urethral hemangioma diagnosed based on urethroscopy and treated surgically were followed for a median length of 50 months. No recurrence or serious complications, such as urethral stricture, urinary incontinence, or retrograde ejaculation, were observed during follow-up. This finding is consistent with those of several recent studies, further confirming the efficacy and safety of transurethral hemostasis/electrocautery in the management of urethral hemangioma (13-15).
In this study, all patients underwent transurethral electrocoagulation or resection, with a postoperative indwelling catheter length of 5 days, and no intraoperative complications were detected. Postoperative hemoglobin levels showed no significant decline, suggesting minimal surgical trauma and effective hemorrhage control. Moreover, the risk of recurrence during follow-up was very low, which is highly consistent with the results of Huang et al. They followed 39 patients for 16 months, and there were only 2 cases of recurrence (4). This suggests that using current endoscopic techniques, thorough electrocoagulation, or laser ablation can effectively obstruct abnormal vascular recanalization and achieve long-term cure.
Laser technology, particularly holmium and thulium lasers, has demonstrated unique advantages in the treatment of urethral hemangioma in recent years (14,16). Genov et al. (17) and Khaitan et al. (12) indicated that lasers offer precision and limited thermal damage and reduce the risk of urethral sphincter contraction, thereby significantly lowering the incidence of postoperative urethral stricture and urinary incontinence. Although laser therapy was not directly employed in this study, the electrocoagulation group achieved comparable outcomes, suggesting that low-power, precise electrocoagulation can achieve similar local control effects when applied by experienced surgeons.
Though minimally invasive, urethral hemangioma surgery carries certain risks of complications, including postoperative bleeding, urethral stricture, sphincter injury, and rectal damage (10,18,19). The absence of these complications in this study may be attributed to a combination of technical and postoperative management factors. Firstly, the procedures adhered to consensus guidelines by employing precise operative techniques with low-power settings, utilizing short and targeted movements to minimize extensive thermal damage (4,10). Furthermore, meticulous intraoperative examination of the verumontanum, supplemented by seminal vesicle massage, was conducted to identify and exclude concurrent seminal tract bleeding, ensuring targeted treatment (4). Finally, a tailored postoperative approach was adopted, whereby the duration of catheter indwelling was adjusted individually, typically up to 5 days, based on the initial lesion size and the extent of coagulation. This individualized strategy effectively mitigated the risks of urinary retention and infection (20-22). Notably, in this study, 89.6% of patients had multiple hemangiomas, suggesting a tendency for multifocal growth. Therefore, systematic intraoperative examination of the entire urethra is crucial to avoid missing minor lesions, which is key to preventing postoperative recurrence (4,23).
Although no recurrence was observed in this study, consensus indicates that recurrence remains a relatively common postoperative complication, often occurring months to years after the surgery (23). The underlying pathophysiological mechanisms are multifaceted, encompassing neovascularization concomitant with urethral epithelial healing, incomplete occlusion of vascular sinuses during the initial procedure, and the presence of predisposing etiologies, such as chronic inflammation and localized hemodynamic perturbations (4,23). Huang et al. (4) reported two recurrent cases where new hemangioma-like changes appeared outside the original surgical area, suggesting that recurrence may not be a reactivation of the primary lesion but rather a manifestation of overall abnormalities in the urethral vascular system. Thus, long-term follow-up is essential for the timely detection and management of new lesions.
There were several limitations to this study. Firstly, the small sample size (n=29) and retrospective design may have introduced selection bias. Secondly, all patients were from two medical centers with homogeneous surgical techniques and postoperative management, limiting generalizability. Thirdly, follow-up relied on telephone and outpatient reviews, potentially leading to loss to follow-up or subjective reporting bias. The absence of follow-up cystoscopy, the gold standard method for detecting recurrence, did not allow the accurate assessment of asymptomatic events. Additionally, the lack of validated questionnaires may have introduced recall bias regarding subjective symptoms. Although telephone follow-up was employed to maximize response rates and reflects real-world clinical practice, our findings should be interpreted cautiously due to this methodological limitation. Finally, the absence of a control group for conservative or pharmacological treatments precludes direct comparison of long-term efficacy across different management strategies.
Future multicenter, prospective, large-scale cohort studies are needed to validate our findings. Such studies should incorporate quality of life assessment indicators to comprehensively evaluate the long-term physiological and psychological impacts of surgical treatment. Additionally, molecular biological studies on pathological specimens are encouraged to explore the pathogenesis of urethral hemangioma and recurrence-related markers.
Conclusions
In summary, this study revealed that transurethral hemostasis/electrocautery offers high long-term stability and minor complications for male urethral hemangioma, representing a safe and effective treatment option. In line with expert consensus recommendations, clinical practice should enhance awareness of this condition, improve early diagnosis rates, and individualize surgical approach selection to optimize the outcomes and quality of life of patients.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0116/rc
Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0116/dss
Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0116/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0116/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Medical Ethical Committees of The Second Affiliated Hospital of the Army Medical University. All patients provided written informed consent.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
- Illescas Megias V, Saez Barranquero F, Rojo Carmona LE, et al. Hemangioma of the glans penis. Arch Esp Urol 2014;67:357-9.
- Efthimiou I, Kavouras D, Vasilakis P, et al. Hemangioma of penile urethra-treatment with simple transurethral excision: a case report. Cases J 2009;2:6199. [Crossref] [PubMed]
- Yong F, Juan L, Jinhuan W, et al. Urethral cavernous hemangioma: a highly misdiagnosed disease (a case report of two patients and literature review). BMC Urol 2019;19:13. [Crossref] [PubMed]
- Huang ZM, Li YF, Wang Q, et al. Clinical characteristics and endoscopic treatment of hematospermia with postcoital hematuria. BMC Urol 2020;20:78. [Crossref] [PubMed]
- Han H, Zhou XG, Fan DD, et al. An Unusual Etiology for Hematospermia and Treatments That Were Successful. Urology 2015;86:740-3. [Crossref] [PubMed]
- McCREA LE. Angioma of the male urethra; review of the literature; report of a case. Urol Cutaneous Rev 1948;52:204.
- Hayashi T, Igarashi K, Sekine H. Urethral hemangioma: case report. J Urol 1997;158:539-40. [Crossref] [PubMed]
- Liu L, Xiao Y, Yue X, et al. Extremely rare pediatric primary scrotum tumor: spermatic cord hemolymphangioma for a case report and literature review. World J Surg Oncol 2023;21:226. [Crossref] [PubMed]
- Parshad S, Yadav SP, Arora B. Urethral hemangioma. An unusual cause of hematuria. Urol Int 2001;66:43-5.
- Alam R, Rostom M, Cohen AJ. Management of Urethral Hemangioma. Urology 2022;160:227. [Crossref] [PubMed]
- de León JP, Arce J, Gausa L, et al. Hemangioma of the prostatic urethra: holmium laser treatment. Urol Int 2008;80:108-10. [Crossref] [PubMed]
- Khaitan A, Hemal AK. Urethral hemangioma: laser treatment. Int Urol Nephrol 2000;32:285-6. [Crossref] [PubMed]
- Tian L, Han H, Lei HE, et al. Clinical features of haematospermia associated with seminal vesicle calculi versus posterior urethral haemangioma. Andrologia 2018;50:e13072. [Crossref] [PubMed]
- Pal AK, Naredi BK, Manikandan R, et al. Recurrent Hemangioma of the Penile Urethra - An Unusual Etiology of Gross Hematuria Managed Successfully with Holmium Laser Coagulation. J Indian Assoc Pediatr Surg 2023;28:62-5. [Crossref] [PubMed]
- Lei H, Guan X, Han H, et al. Painless Urethral Bleeding During Penile Erection in an Adult Man With Klippel-Trenaunay Syndrome: A Case Report. Sex Med 2018;6:180-3. [Crossref] [PubMed]
- Ikeda J, Taniguchi H, Inoue M, et al. Urethral Hemangioma Treated With Transurethral Coagulation Using Narrow-Band Imaging: A Case Report. Cureus 2025;17:e82791. [Crossref] [PubMed]
- Genov P, Conkova E, Hristova I, et al. A rare case of urethral hemangioma treated with LASER. Urol Case Rep 2022;43:102067. [Crossref] [PubMed]
- Li YF, Liang PH, Sun ZY, et al. Imaging diagnosis, transurethral endoscopic observation, and management of 43 cases of persistent and refractory hematospermia. J Androl 2012;33:906-16. [Crossref] [PubMed]
- Qian X, Tao X, Liu H, et al. One rare case of posterior urethral hemangioma and review of the literature. Urol Case Rep 2022;45:102190. [Crossref] [PubMed]
- Masood A, Hussain I, Khan UU, et al. Hemangioma of penile urethra - Treatment with intralesional triamcinolone. Urol Case Rep 2021;35:101494. [Crossref] [PubMed]
- Mandal S, Nayak P, Purkait S, et al. Rare Images of Urethral Hemangioma and its Management. Urology 2019;124:e9-e11. [Crossref] [PubMed]
- Safar O, Al-Qahtani A, Al-Qahtani S. Urinary Bladder Hemangioma Successfully Treated by Angioembolization with Long-Term Follow-Up: Case Report and Literature Review. Diagnostics (Basel) 2023;13:875. [Crossref] [PubMed]
- Ishikawa K, Sasaki H, Shimoyama H, et al. Urethral hemangioma: How to investigate as a cause of hematuria after male sexual activities. IJU Case Rep 2023;6:454-7. [Crossref] [PubMed]
